Consent For Care And Treatment Form Page 2
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4Name: _______________________ DOB: _________ Chart Number: ________
History and Physical
Medical History:
Alcoholism
Blood disorders
Circulation problems
sculoskeletal
Breathing issues
Liver
Sleep apnea
Gout
Allergies
Heart disease
Asthma
Heart murmur
Depression
nxiety disorder
ental illness
Kidney disease
Stomach/bowel
Blood clot
High cholesterol
High blood pressure
Hepatitis
Neuropathy (specify) ___________
Thyroid disease (specify) ____________
Diabetes (type 1, type 2)
Arthritis (specify) _____________
ther (specify)
____________
HIV
CVA
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Skin disorders
Stroke
Surgical History
None
-
s
Cholecystectomy
Have you ever had any surgical procedures on foot/ankle or anywhere else on your body?
Yes
No
If yes, please describe: _________________________________________________________________________________
Do you have any artificial joints?
Yes (where? __________)
No Do you have an artificial heart valve?
Yes
No
Social History
Do you drink alcohol?
Yes, everyday (5-7 days/week)
Yes, occasionally/socially
No/Rarely
Substance abuse:
Yes, I have a current substance abuse problem. Please specify: __________________________
Yes, I had a past substance abuse problem. Please specify: ________________________________________________
No, I have never had a substance abuse problem
What is your occupation? _____________________________________ Does it involve mostly
standing or
sitting
Do you exercise regularly?
No, I do not exercise regularly
Yes, I do the following regular exercise: _____________
____________________________________________________________________________________________
_
Family History Is there any family history (blood relative) of: (Please indicate family member)
Alzheimer’s
_____________________
Depression
_____________________
Arthritis
_____________________
Diabetes
_____________________
Bleeding disorders
_____________________
Emphysema
_____________________
Blood clot
_____________________
Heart disease
_____________________
Cancer
_____________________
High Blood Pressure _____________________
Cataracts
_____________________
Neurological
_____________________
Circulation problems_____________________
Strokes
_____________________
Other (specify):
_____________________
Review of Systems
(Please check the box if you currently have any of these symptoms or check “NONE”)
Cardiovascular
leg pain when walking
fever
chest pain/pressure
leg swelling
cold hands/feet
fainting
palpitations
vascular disease
valve problems
NONE
Genitourinary
increased urgency
excessive urination
kidney disease
kidney stones
NONE
Gastrointestinal
abdominal pain
heartburn
blood in stool
vomiting
ulcers
constipation
diarrhea
trouble swallowing
decrease appetite
increase appetite
NONE
Integumentary
athletes foot
nail abnormalities
keloids
itchiness
dry, scaly skin
NONE
Hematologic
lower leg ulcers
sickle cell disease
anemia
blood thinners
clotting disorders NONE
Neurological
tingling
weakness
seizures
numbness
headaches
tremors
paralysis
NONE
Musculoskeletal
back pain
joint swelling
muscle weakness
muscle pain
neck pain
sciatica
joint stiffness
joint pain
joint instability
arthritis
NONE
Respiratory
chest pain
wheezing
COPD
coughing
snoring
shortness of breath
emphysema
NONE
PLEASE READ AND SIGN
The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for
notifying the physician and/or medical staff of any and all updates to the information listed above.
Patient Signature: _______________________________________
Date: ________________________
Rev 12/29/2011
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